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Corresponding author at: SAMU de Paris-DAR Necker University Hospital-Assistance Public Hopitaux de Paris, Paris, France.
Affiliations
SAMU de Paris-DAR Necker University Hospital-Assistance Public Hopitaux de Paris, Paris, FranceParis Descartes University, Paris, FranceINSERM U970 Team 4 “Sudden Death Expertise Center”, Paris, France
Paris Descartes University, Paris, FranceDepartment of Anesthesia and Intensive Care HEGP University Hospital-Assistance Public Hopitaux de Paris, Paris, France
Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry.
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pre-hospital setting: an additional resuscitation option for uncontrolled catastrophic hemorrhage.
]. The Service d’Aide Medicale Urgente (SAMU) Paris, a physician-delivered prehospital service already performing extracorporeal life support (ECPR) has recently incorporated REBOA into its practice. We describe the first prehospital Zone 1 (proximal descending aorta) placement.
Multiple EMS teams, including a SAMU unit, were dispatched to the scene of a 49-year-old woman who dropped 30 feet onto a highway after jumping from a bridge. They arrived within 12 min of the call. An off-duty nurse had already initiated cardiopulmonary resuscitation (CPR).
The cardiac rhythm was asystole. Initial resuscitation included intubation, intravenous access, and fluid and epinephrine boluses. There was no obvious head or chest injury. The patient was very pale with a markedly distended abdomen. Given the concern for blunt traumatic arrest with exsanguinating abdominal torso hemorrhage and continued arrest, the SAMU physician proceeded with REBOA (Photo1 ). A 7-French sheath was placed through modified cutdown technique onto the common femoral artery. The REBOA catheter (Prytime Medical, Boerne, Texas, USA) was measured and placed successfully into Zone 1. The balloon was inflated within 17 min of team arrival. Within 5 min of occlusion, there was return of circulation. The patient was transported directly to the trauma center’s operating room, arriving within 36 min of occlusion.
Photo 1Insertion of Zone 1 Resuscitative Endovascular Balloon Occlusion (REBOA) in prehospital setting.
Operative findings included diaphragmatic rupture, a high-grade liver laceration, and significant retroperitoneal hematoma. Although she survived her damage control surgery, unfortunately she was found to have advanced metastatic cancer. The decision was made to move to palliative care.
REBOA represents a less invasive method of aortic occlusion than resuscitative thoracotomy. Thoracotomy experience is also limited in many European countries due to low incidence of penetrating trauma. Non-traumatic torso hemorrhage e.g. obstetric hemorrhage, can also be managed with REBOA.
Early intervention is critical to decrease preventable hemorrhage-related mortality. Point-of-care hemorrhage control is achieved through appropriate implementation of REBOA into prehospital systems. The Paris SAMU, building on their existing experience with prehospital ECPR, has incorporated REBOA [
A pre-hospital extracorporeal cardiopulmonary resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: an observational study and propensity analysis.
]. REBOA can potentially extend the survival time and resource utilization when multiple exsanguinating casualties from mass casualty incidents are moved to the warm zone, part of a “damage control ground zero” concept.
It is imperative that REBOA is developed within a system that can rapidly transport to definitive care. REBOA should be placed only by those who have undergone appropriate training in patient selection and use. Point-of-care ultrasound can assist in identifying appropriate patients, and in excluding contraindications e.g. pericardial tamponade. Every case should undergo peer review to ensure quality assurance.
This is the first reported case of successful civilian prehospital Zone 1 deployment – a product of extensive training and development within a robust system incorporating an overall “damage control ground zero” concept.
Consent
Appropriate consent was obtained from the patient’s family to report this case.
Conflicts of interest
All authors declare have no conflicts of interest.
References
Kisat M.
Morrison J.J.
Hashmi Z.G.
Efron D.T.
Rasmussen T.E.
Haider A.H.
Epidemiology and outcomes of non-compressible torso hemorrhage.
Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry.
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pre-hospital setting: an additional resuscitation option for uncontrolled catastrophic hemorrhage.
A pre-hospital extracorporeal cardiopulmonary resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: an observational study and propensity analysis.
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